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Master of Social Work Clinical Research Papers School of Social Work

5-2013

Key Elements of Dialectical Behavior Therapy Key Elements of Dialectical Behavior Therapy

Cheryl A. Nickelson St. Catherine University

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KEY ELEMENTS OF DIALECTICAL BEHAVIOR THERAPY

MSW Clinical Research Paper

Cheryl A. Nickelson

School of Social Work

St. Catherine University and the University of St. Thomas

St. Paul, MN

Committee Members

Karen Carlson, Chair, MSW, LICSW, Ph.D.

Miriam Itzkowitz MSW, LICSW

Sarah Cherwien, Psy.D.

ii

Abstract

The purpose of this study was to explore the research question: what are the key elements

of Dialectical Behavior Therapy (DBT) that make it effective when working with people

with a diagnosis of Borderline Personality Disorder (BPD)? Using a qualitative design, 6

participants from mental health agencies in Twin Cities, MN were interviewed. A semi-

structured interview of fourteen questions was used based on the literature review to

further explore the research question. Findings suggest that there is not one main element

that makes DBT effective when using DBT with people with a diagnosis of BPD, but

several elements that come together in order to make it an effective treatment approach.

The therapists provided supporting evidence that DBT is an effective treatment model

with this population.

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Acknowledgements

I first would like to thank God for giving me the strength to push through and keep

pressing. Thank you to all of my family, I am truly thankful and so blessed to have you.

Thank you for everything you have done. Ava Marie & Vito Corleone, when things got

stressful and life seemed chaotic; your smiles are what kept me going. The both of you

are my world. Thank you to my chair and my committee members.

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Table of Contents

1. Abstract……………………………………………………………………………ii

2. Acknowledgements……………………………………………………..………..iii

3. Table of Contents……………………………………………………..…………..iv

4. Introduction…………………………………………………………...…………..v

5. Literature Review………………………………………...…………………….xvii

6. Conceptual Framework…………………………………………….………xvii-xix

7. Research Question………………………………………………………….……xx

8. Methods…………………………………………………………..………………xx

Research Design……………………………………………….………………..xxi

Sample…………………………………………………………..………………xxi

Protection of Human Subjects………………………………...……………xxi-xxii

Data Collection……………………………………………...……………xxii-xxiii

Data Analysis………………………………………………….………………xxiii

9. Findings…………………………………………………..………………xxiii-xxix

10. Discussion………………………………………………....……………xxix-xxxiii

11. Strengths and Limitations……………………………………..………xxxiii-xxxiv

12. Implications for Social Work Practice……………………………….………xxxiv

13. References………………………………………………….……..……xxxv-xxxvi

14. Appendix A……………………………………………...……………xxxvii-xxxix

15. Appendix B…………………………………………………………………….…xl

16. Appendix C………………………………………………………………………xli

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People with a diagnosis of Borderline Personality Disorder (BPD) have been looked at in

the mental health field as difficult and challenging to treat (Chapman, 2006). Individuals

diagnosed with BPD constitute 2-3% of the general U.S population (Fraser & Solovey,

2007). 70-75% of persons diagnosed with BPD have engaged in a self-injurious act

which is defined as “any intentional acute self-injurious behavior with or without suicidal

intent including both suicide attempts and self-injurious behaviors” (Fraser & Solovey,

p.249, 2007).

Individuals experience dysregulation in many areas such as emotional,

interpersonal, and behavioral with emotional dysregulation being the main element of the

disorder (Linehan, p. 6-7, 1993). Clients meeting the criteria for BPD have difficulty in a

number of areas such as regulating their emotions, stability in their relationships, coping

and effectively dealing with stressful situations, crises, and the ability to be present in the

moment (Linehan, 1993).

In 1993, Marsha Linehan developed a model of treatment called Dialectical

Behavior Therapy (DBT). DBT was initially created in order to effectively help those

diagnosed with BPD who was suicidal and inflicting harm upon themselves (Slepp,

Epler, Jahng & Trull, 2008). DBT has been shown in a number of studies to be the first

effective treatment model developed for clients diagnosed with BPD (Linehan, 1993).

One of the most important elements of the treatment process in this model is the

relationship between the therapist and the client (Linehan, 1993). The therapist plays a

crucial role in the treatment process because they establish treatment goals and targets

with the client and coach them on effectively reducing harmful behaviors, and sticking to

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their treatment goals, essentially helping them to establish a “life worth living”. The

primary targeted goal of DBT is to help the patient engage in a “life worth living” even

when intense emotions are present. (Lynch, Trost, Salsman & Linehan, 2007).

The following literature review demonstrates the effectiveness of DBT when

working with BPD clients. There are many elements to DBT that make it an effective

form of treatment. The themes identified below illustrate the important elements of DBT.

Literature Review

Borderline Personality Disorder (BPD)

Borderline Personality Disorder is a widespread personality disorder that carries

significant risks and associate behaviors could be fatal if it is not treated effectively.

Clients who have been diagnosed as meeting the criteria for Borderline Personality

Disorder (BPD) experience a variety of chaotic symptoms. Among people with

personality disorders, BPD has been known to be related to most attempted suicides, as

well as most completed suicides (Linehan, 1993).

Symptoms that are experienced are outlined in the DSM-IV-TR (2000).

According to the DSM-IV-TR (2000) the diagnostic criteria for 301.83 Borderline

Personality Disorder is “a pervasive pattern of instability of interpersonal relationships,

self-image, and effects, and marked impulsivity beginning by early adulthood and present

in a variety of contexts, as indicated by five (or more) of the following:

(1) Frantic efforts to avoid real or imagined abandonment.

(2) A pattern of unstable and intense interpersonal relationships characterized by

alternating between extremes of idealization and devaluation

(3) Identity disturbance: markedly and persistently unstable self-image or sense of

self

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(4) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending,

sex, substance abuse, reckless driving, binge eating).

(5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) Affective instability due to a marked reactivity of mood (e.g., intense episodic

dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a

few days)

(7) Chronic feelings of emptiness

(8) Inappropriate, intense anger or difficult controlling anger (e.g., frequent displays

of temper, constant anger, recurrent physical fights)

(9) Transient, stress-related paranoid ideation or severe dissociative symptoms

(American Psychiatric Association, 2000, p. 710).

Individuals diagnosed with Borderline Personality Disorder experience

dysregulation in areas such as emotional, interpersonal, and behavioral dysregulation

(Linehan, 1993). Dialectical Behavior therapists focus on these dysregulated areas with

clients by using a number of different strategies such as group skills training, individual

therapy, and phone consultation. Within these different strategies the therapist uses

acceptance, validation, change, and problem solving, while holding a dialectical

viewpoint and teaching the client about the biosocial theory (Linehan, 1993).

Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy (DBT) was specifically developed to effectively

target women with Borderline Personality Disorder (BPD) who were struggling with

suicidal thoughts and behaviors (Miller, Koerner & Kanter, 1998). Elements that make

this treatment model that make it effective include the hierarchy of the model, different

treatment targets, stages and strategies. The dialectical viewpoint and the biosocial theory

are two elements of this treatment model that differ from other Cognitive Behavior

Therapies (Chapman, 2006).

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A crucial piece of this treatment model is the therapeutic relationship between the

client and the therapist. In order for the therapy to be effective, the therapist must accept

the client as he or she is, and emphasizes validation and acceptance throughout the

treatment process (Linehan, 1993).

The term “dialectical” is what makes DBT different than other treatment models.

Essentially, having a dialectical viewpoint means finding the middle balance between two

opposing viewpoints. On one end of a pole there is an opposing viewpoint and on the

other end there is an opposite viewpoint. One end is referred to as the “thesis” and the

opposite end is the “anti-thesis” (Dimeff & Koerner, 2007). An example of this, would be

when a client indicates, “I want to live a healthy lifestyle and not engage in self-inflicting

behaviors anymore” and the next day the client comes to the therapist and states, “I am

unable to contract for safely, I want to cut myself”. These two ideas are in conflict with

one another. In this case, the therapists job to acknowledge and validate the client and to

work with the client to find that middle ground which is referred to as the “synthesis”

(Dimeff & Koerner, 2007).

Furthermore, the overall goal of DBT is to coach the individual through their

hardships so that the individual is able to learn new skills and then apply the skills to their

life in order to live a life without everyday crises, without suicidal and self-destructive

behaviors, and without other destructive behaviors that interfere with living a healthy

lifestyle. Ultimately the therapist’s goal is to assist the client to find ways for the client to

function at their fullest potential after treatment and to be able to cope with their

emotions. Skills that the therapist teaches the client are core mindfulness, distress

tolerance, emotional regulation, and interpersonal effectiveness skills (Moonshine, 2008).

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It is through skills training and a number of other strategies that DBT addresses these

areas that are dysregulated.

Treatment Stages

Pretreatment Stage: Prior to the beginning of treatment the client and the

therapist outline treatment targets and goals that needs to be worked on in order for the

client to eliminate unhealthy behaviors and live to his or her fullest potential. This is

referred to as the pretreatment stage (Porr, 2006). This is one of the most important

aspects of the treatment process because if the client does not agree on the targeted

treatment goals and cannot commit to first work towards eliminating suicidal and self-

inflicting behaviors then treatment cannot proceed (Lynch et al., 2007).

Because the treatment stages are structured within a hierarchy of importance, the

therapist works on the most important aspects first and, as the client makes progress, the

therapist moves to the next stage. The purpose of structure is to help the client to first

eliminate destructive behaviors, suicidal and self-destructive behaviors, and learn to gain

skills to be able to cope and handle distress when in crisis. Swales (2010) stated;

“Without structure, the therapist may rush from crisis to crisis helping the client to

extinguish fires but never teaching the client how to prevent them” (Swales, 2000, p. 10).

It is important in DBT to follow the stages of DBT therapy in order to teach the client

how to prevent the crisis from happening by coaching them on the skills to use so that

they are able to cope and prevent the crisis from happening or reduce and eliminate

unhealthy behaviors that are destructive to a person’s life (Swales, 2000).

The client must agree to work towards the treatment goal of committing to

treatment and eliminating self-destructive behaviors or else treatment cannot proceed.

x

The reason this stage is crucial to the clients treatment is because as Porr (2010) stated

“no one can do effective therapy if the client is dead” (Porr, 2010, p.121). The client has

a responsibility of committing to treatment and working towards eliminating behaviors

that are destructive and interfering with his or her life (Porr, 2010).

Furthermore, it is important to note that the therapist may have to connect the

treatment stages together, or often times go back and review a treatment stage if the client

loses sight of their treatment goals or goes against their treatment commitment (Dimeff &

Koemer, 2007). One important piece for therapists to remember is that they must be

willing to meet and accept the clients as they are (Swenson, Sanderson, Dulit & Linehan,

2001). Following the pre-treatment stage, there are three treatment stages which serve as

a hierarchy of importance.

Stage One: There are many parts to this stage that are targeted such as:

Eliminating self-inflicting and suicidal behaviors

Therapy interfering behaviors: resistant to the treatment process

Life interfering behaviors: drug or excessive alcohol use and impulsive behaviors

(Porr, 2010). Before the client can proceed to the next stage which focuses on

post-traumatic stress the client must have made progress and shown the therapist

that he or she is able to cope with painful emotions (Linehan, 1993).

Stage Two: After the client has made progress and eliminated the targeted

treatment goals of stage one; the therapist will work on helping the client to resolve:

Post-traumatic stress

Emotional distress (Dimeff & Koemer, 2007).

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This stage could be a difficult one for clients because the client is now exposed to his

or her agonizing emotions, and has to learn to use his or her new skills to cope with

them and handle the distress effectively (Porr, 2010). If the client does not possess the

skills to cope with the exposure of painful emotions, treatment in this stage would not

be effective. The client must use and know the skills before issues within this stage

are addressed (Swales, 2000).

Stage Three: The last stage of the treatment hierarchy is addressed when the

client is moving toward independence and is terminating his or her treatment. Before

treatment is terminated the therapist works with the client on the following areas:

Increase self-respect

Work toward individual goals that the client wants to pursue

Works with the client on trusting and validating themselves, their emotions and

their behaviors (Linehan, 1993).

Treatment Modes

There are four different approaches in DBT that may serve as interventions for the

client and the therapist. DBT consists of group therapy, individual therapy, phone

consultation with the therapist and consultation meetings for the therapist (Soler, et. al,

2009). The purpose of these different approaches is to ensure that DBT is taught

effectively. Specific modes of interventions are discussed below.

Individual Therapy: Individual therapy serves as an opportunity for the client

and the therapist to come together one on one and discuss the client’s treatment goals and

targets. This typically is once a week for 60-90 minutes; however, the time could vary.

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The overall goal is to eliminate destructive behaviors and replace them with skills that

produce effective responses to crisis. The therapist does this by assessing factors that

produce maladaptive behaviors and factors that produce effective behaviors (Linehan,

1993). The therapist also gives the client homework assignments that will help the client

with their use of skills and coaches the client on what skills to use in regards to life crises

(Lindenboim, Chapman & Linehan, 2007). If a client needs assistance outside of their

individual therapy or skill groups they may consult with their therapist by phone

consultation.

Phone Consultation: Outside of therapy sessions and group skills the client may

need support when faced with a crisis or distressful situation. The therapist would then

coach the client on what skill would best apply to the situation and process with the client

effective ways of coping with the stressful event (Feigenbaum, 2007). Telephone

consultation gives the client an opportunity to ask for help and identify what skill to use

at the present time (Feigenbaum, 2007). Therapists who use DBT encourage their clients

to call them before they have harmed themselves so that the therapist is able to address

the crisis and help the client identify what skill he or she should use in present time. The

purpose of this is to reduce and prevent suicidal behaviors and self-harm. Individuals

meeting the criteria for BPD often times have a difficult time applying the skills they

learn in skills training and in their individual therapy sessions to real life situations. The

therapist is able to help the client identify what skill they should use given the situation or

crisis (Ben-Porath & Koons, 2005).

Group Skills Training: Skills’ training is an important piece of DBT and

consists of four different modules including:

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Core Mindfulness

Emotional Regulation

Interpersonal Effectiveness

Distress Tolerance (Linehan, 1993).

Group skills training gives the client an opportunity to learn and implement the skills in a

group setting with other individuals in treatment (Feigenbaum, 2007). The purpose of

skills training is to help the client implement effective practical skills into their life that

they can use in times of distress and eliminate other unhealthy and negative behaviors.

In a study conducted by Stepp, Epler, Jahnag & Trull (2008), researchers

examined how effective DBT skills’ training are when working with BPD clients and the

how much of an impact skills training had on clients receiving it. Results showed that the

use of skills increased considerably with DBT training. In this study, participants reported

how often he or she used the skills. Core mindfulness skills were used 44% of the time,

distress tolerance skills were used 29%, emotion regulation skills were used 18% and

interpersonal relationship skills were reported being used 9% of the time (Stepp, Epler,

Jahnag & Trull, 2008).

In addition, Stepp, Epler, Jahnag & Trull (2008) reported that other researchers

discovered that distress tolerance and core mindfulness were the two skills that were used

most frequently compared to the other skills. It was also determined that specific

behaviors had decreased due to skill use such as, emotional instability; additionally,

identity issues had decreased and relationships had improved among the participants

(Stepp, Epler, Jahnag & Trull, 2008).

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Core Mindfulness: One of the central skills of DBT taught throughout the

treatment process is mindfulness, which stems from Zen Western practices (Feigenbaum,

2007). Core mindfulness teaches the client to stay in the moment, not to ruminate about

the past and to do one thing at a time. This skill helps the client to stay in the present

moment and to be aware of what is going on around them. This skill also helps the BPD

client focus on reality in any situation and not allow their emotions to take over (Porr,

2010).

A recent study examined core mindfulness in DBT when working with clients

with a diagnosis of BPD. The purpose of the study was to see if this skill helps improve

symptoms of BPD and if the skill use increases over time. The results of the study

showed an increase in the clients skill use over time (Perroud, Nicastro, Jermann &

Hugulet, 2012).

Distress Tolerance: The next acceptance skill is distress tolerance. It is important

that the therapist emphasizes throughout treatment that crises, distress and painful

situations and events are going to occur because they are all a part of life. It is about what

the person does during the crisis or when they are experiencing pain that matters.

Learning to accept and cope with painful situations effectively is essential in life. The

skills that are taught in this module to help with distress are distracting, self-soothe

(McMain, Korman & Dimeff, 2001), improving the moment and evaluating the pros and

cons of the situation (Linehan, 1993). These skills are important for clients to use before

a crisis, in the middle of a crisis and after.

xv

Interpersonal Effectiveness: This skill module helps the client with many areas

such as, asking for what he or she needs or wants but also coping with being told “No”. It

also helps the client build their skills in order meet a goal and to help their interpersonal

relationships (Moonshine, p. 70 2009). It is common among the population of people

with BPD that clients will terminate relationships early simply because they do not have

the skills to cope and manage the relationship. The goal of this skill module is to enhance

the clients relationships, self-respect and their assertiveness by teaching the client

interpersonal effectiveness skills (Linehan, 1993).

Emotion Regulation: This skill module addresses the core area in individuals

diagnosed with BPD that is dysregulated. The therapist coaches the client on emotion

regulation skills in order to effectively cope with painful emotions and stressful

situations. In order for the client to make behavior changes, such as reducing

impulsiveness, he or she needs to know the skills and utilize them in order to cope

effectively with the painful emotion (McMain & Dimeff, 2001). There are several skills

within this module that the therapist teaches the client. Emotion regulation skills are an

important element to DBT therapy because of the difficultly people with this diagnosis

have with regulating his or her emotions effectively and because emotion is the main area

that is dysregulated among this people with this diagnosis. It is important that individuals

with BPD learn how to cope with their emotions in a healthy manner (Linehan, 1993).

Chain Analysis: Chain analysis is completed in order to analyze a problem

behavior. It gives the client an opportunity to process the problem behavior with the

therapist. It is said to be one of the most important pieces to this treatment modality

xvi

(Linehan, 1993). The purpose of a chain analysis is to determine what the problem is,

what caused the problem and solutions to solve the problem (Linehan, 1993).

Consultation: While the previous three interventions focus on the client, this one

addresses the therapist. This is an opportunity for the therapist to meet once a week with

their treatment team to provide a sense of support to decrease the chances of burnout. It

gives the therapist an opportunity to discuss and process through each of their caseloads,

situations, questions or concerns that the therapist may have (Soler et al., 2009).

Assumptions

There are eight assumptions within DBT that are helpful for the therapist to keep in

mind when working with a difficult client. These assumptions focus on acceptance and

change of the client and serve as a framework for the client’s treatment (Linehan, 1993). I

have chosen four that highlight the importance of these assumptions.

1. “Patients Are Doing the Best They Can”: It is important for the therapist to

believe the assumption that clients are doing the best that they can with the skills

that they have or don’t have.

2. “Patients Want to Improve”: It is important for the therapist to be mindful that the

client enters treatment not having the skills that he or she needs in order to be

effective in certain situations. The client enters treatment to gain the skills he or

she needs and to gain support

3. “Patients Need to Do Better, Try Harder, and Be More Motivated to Change”. It

is important for the therapist to encourage and motivate the clients and inform

them that their therapy progress is up to them and that the therapist is there to help

the patient reach their goal of having a life worth living. It is common among this

population that the clients want to live a healthy life, but then engage in self

inflicting behaviors which contradict that.

4. “Therapist Treating Borderline Patients Need Support”, it is important that

therapist have support when treating this population so that they don’t burn out

(Linehan, p. 106-108, 1993).

xvii

This purpose of this clinical research project is to answer the question: what are the key

elements that make Dialectical Behavior Therapy (DBT) an effective treatment model

when working with clients diagnosed with Borderline Personality Disorder (BPD)?

Evidence Based Research

A number of studies have examined the effectiveness of DBT in comparison with

other treatment models. In a study conducted by Linehan (1993), researchers examined

the effectiveness of DBT in comparison to “Treatment as Usual” (TAU). Results

indicated that DBT was more effective in a number of areas such as, fewer participants

withdrawing from treatment, participants less prone to enter the hospital related to BPD

symptoms, and clients participating in DBT rather than TAU stayed fewer days in the

hospital. In fact, according to Linehan (1993) clients receiving DBT had an average of

8.46 days in the hospital compared to 38.36 for those clients receiving TAU. These

numbers reflect clients in treatment for a year span. Clients receiving DBT treatment

rated higher on a global adjustment scale after they had completed treatment and also

indicated that they had improved their work, school and household roles (Linehan, 1993).

Conceptual Framework

The purpose of this section is to describe the conceptual framework that has

influenced the literature review, the overall research question and the study. The theories

that impact and are relevant to Dialectical Behavior Therapy and Borderline Personality

Disorder are the biosocial theory, which is common throughout DBT, and the dialectical

perspective. Both of these pieces make DBT unique from other cognitive behavioral

treatments.

xviii

Biosocial Theory

This theory is derived from the belief that clients with BPD grow up in

invalidating environments and therefore lack the skills needed to cope with regulating

their emotions. There are many negative consequences of an invalidating environment.

As discussed in Fraser and Solovey (2007), an invalidating environment as “emotional

experiences and interpretations of events are often not taken as valid responses to events;

are punished, trivialized, dismissed or disregarded; and/or are attributed to socially

unacceptable characteristics such as over reactivity, inability to see things realistically,

lack of motivation, motivation to harm or manipulate, lack of discipline, or failure to

adopt a positive attitude” (Fraser & Solovey, 2007, p. 251). In a healthy parent/child

relationship the child’s distress is met with nurturing and responsiveness. In an

invalidating environment, a child cries might be met with harsh words and an invalidating

response. As a result of an invalidating environment, the child grow ups lacking the skills

needed to regulate their emotions, handle distressful situations, unable to trust their own

emotions or label them (Linehan, 1993, p.3).

The second belief within biosocial theory is that there is a biological basis that

affects the way a person with BPD regulates their emotions. Clients with BPD lack the

skills needed to cope with distress and crisis situations and therefore they steer toward

using self-destructive and harmful behaviors to cope (Lynch, Trost, Salsman & Linehan,

2007). Typically, a person meeting the criteria for BPD who engages in self-inflicting

behaviors does this in order to cope with the stressful situation. This relieves the stress for

a short time causing the painful emotions to diminish (Dimeff & Koerner, 2007).

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Dialectical World View

The central aim of dialectics is creating balance. Imagine a line with two things

on opposite ends of the line that may be in conflict or opposites of each other. The goal is

to create balance between the two (Moonshine, 2008). An example of this would be when

a client doesn’t want to live in agony anymore but doesn’t want to put forth the effort to

change or a client who wants his or her life to be better but still engages in destructive

behavior (Moonshine, 2008). Dialectics consists of three different phases. The first stage

(the thesis) consists of a positive assertion such as “I want to change, life is worth

living!” The second stage (the anti-thesis) is a contradiction of the first stage, such as

continuing to engage in destructive behaviors. In the final stage (the synthesis) two of the

previous stages are resolved therefore; balance is achieved.

The goal of DBT is to search for the middle ground and achieve balance.

(Linehan & Schmidt III, 1995). Those who have BPD experience dialectic failures such

as black and white thinking. The person is stuck between thesis and anti-thesis and is

unable to achieve synthesis (Linehan, 1993). Another part of dialectics is validation and

acceptance. It is of high importance that the therapist validates the client throughout

therapy and find the underlying truth in the clients response or behaviors. The other

aspect of this view point is acceptance. It is important that the therapist accepts the client

as he or she comes into treatment and believes that the client has the ability to change

(Linehan, 1993).

xx

Research Question

My central research question is: what do practitioners in the Twin Cities,

Minnesota area identify as key elements of Dialectical Behavior Therapy that make it

effective when working with clients with Borderline Personality Disorder? There are few

treatment models used to treat Borderline Personality Disorder that are evidenced based,

however DBT has been shown through several randomized clinical trials to be effective.

There are many elements to DBT such as the hierarchy of treatment stages, targets and

strategies, the biosocial theory and dialectical viewpoint that make this treatment model

effective. It is important to know which elements of DBT make it an effective treatment

model since the targeted population experiences a number of very serious issues that are

difficult to treat. Additionally, participants were asked about the training they have

received in the model, as well as their adherence to the model practice. These results as

also briefly reported below.

Methods

The following section presents an overview of the research methodology that was

used in this study. The following areas will be discussed below: the design of the

research, the sample, an overview of the protection of human subjects and the

Institutional Review Board (IRB) consent form, the data collection instrument and

process. The purpose of this research study is to identify what practitioners believe to be

the key elements that make Dialectical Behavior Therapy (DBT) an effective treatment

model when working with clients with Borderline Personality Disorder (BPD).

xxi

Research Design

This research study is a qualitative that examined practitioners’ views on the key

elements of DBT that make it an effective treatment model when working with BPD

clients. The researcher conducted 6 interviews with therapists at agencies that specialize

in DBT located in the Twin Cities, MN area. The purpose of conducting interviews was

to get in depth responses from the practitioners who have experience in using DBT as a

treatment modality. The interviews were conducted by telephone and required

approximately 35-40 minutes of practitioners’ time. The researcher asked fourteen

questions designed to highlight the different viewpoints of the key elements of DBT that

make it effective and answer the research question.

Sample

Purposive and random sampling was used for this study. The researcher recruited

participants by conducting an internet search for agencies in the Twin Cities, MN area

that provide DBT services. The researcher then made initial contact with the therapist by

utilizing a phone script introducing the purpose of the research and asked if the therapist

would be interested in participating in the research study (Appendix B). A total of 6

participants were recruited to participate. Five of the participants in the research study

have their Masters of Social Work (MSW) and are Licensed Independent Social Workers

(LICSW). The other participant is a licensed psychologist.

Protection of Human Subjects

The researcher completed the University of St. Thomas Institutional Review

Board (IRB) requirements, including the consent form (Appendix A). The purpose of the

xxii

consent form is to protect human subjects from harm and ensure confidentiality in

research studies. The researcher reviewed and provided each participant a copy of the

consent form. Each participant was required to sign the consent form providing consent

to participate in the study. The participants were given the opportunity to withdrawal

consent and participation from the interview at any time. If participants chose to

withdraw, they were informed that data provided by them would be destroyed.

Confidentiality was maintained throughout the research process by keeping the

data and all audio recordings in a locked file cabinet at the researcher’s home. The data

that the researcher analyzed was kept in a laptop that belongs to the researcher which is

secured with a locked passcode that only the researcher can access. Only the principal

investigator will have access to the data records and any identifying information. The

data will be transcribed from the audio recorder to a word document on a secured laptop

that belongs to the researcher. The researcher will be transcribing all of the interviews.

The data will be kept in a locked file cabinet and on a secured laptop until the end

of May 2013. On May 30th

2013, the data will be destroyed by permanently deleting it off

the secured laptop and all confidential paper data will be shredded. There are no risks or

benefits to this study, nor is there any use of deception.

Data Collection

The six interviews took place over the telephone, per the participants’ request.

The six individual interviews were each approximately 20-35 minutes long. The

participants were asked fourteen questions in order to examine the researcher’s question.

The first five questions refer to the subjects professional background while the other 9 are

xxiii

in regards to their opinion on the key elements of DBT that make it effective when

working with clients with BDP (See Appendix B). If the researcher felt that a question

needed further explanation, additional questions were asked.

Data Analysis

After the collection of the data, all interviews were transcribed. Content analysis

was used while reviewing the data. A partner reliability check was conducted in class, in

order to analyze the data, however confidentiality was maintained. Common themes such

as: the structure/hierarchy of the model, mindfulness, the biosocial theory, the dialectical

viewpoint, consultation teams, and chain analysis were identified within the data and

coded by the researcher. These themes provided the researcher with information relating

to the key elements that participants believe contribute to the effectiveness of Dialectical

Behavior Therapy when working with individuals diagnosed with Borderline Personality

Disorder.

Findings

In order to answer the question: What are practitioners’ views on the key elements

to Dialectical Behavior Therapy when working with people diagnosed with Borderline

Personality Disorder, six interviews were conducted. The following section will discuss

the presented themes.

Training and Adherence to the Model

The participants in this research study were asked several questions such as,

“What is your professional licensure?” “How long have you been working in this field

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with persons with Borderline Personality Disorder, using the DBT treatment model?”

“What type of treatment setting do you practice in, and what is your title? And “Do you

strictly adhere to the Linehan model? The following table represents the information that

was given.

Subjects Professional

Licensure?

Experience? Type of treatment setting? Strictly

Adhere to

the Linehan

Model?

Participant #1 LICSW 14.5 years Private Practice

Psychotherapy

Yes

Participant #2 LICSW 13 years Outpatient Clinical

Therapy

Yes

Participant #3 LICSW 9 years Outpatient mental health

psychotherapy

Yes

Participant #4 LICSW 13 years Private practice

Psychotherapy

Yes

Participant #5 LP 20 years Private Practice Yes

Participant #6 LICSW 17.5 years Outpatient Mental Health

Clinic

Yes

Structure/Hierarchy of the model

All six participants acknowledged that the structure and hierarchy of the model is

one of the key elements that make Dialectical Behavior Therapy effective when working

with Borderline Personality Disorder. The following quotations are from the six

participants interviewed.

Another participant indicated, “There is a hierarchy, in other words if someone is

engaging in self harm or suicidal behavior, that is what we deal with first, if there is

none of that then we deal with therapy interfering behaviors and if there is none of

that, we deal with everything else then and all of the life interfering behaviors”.

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Core Mindfulness

Five of the six participants indicated that mindfulness is a key component to

Dialectical Behavior Therapy. Core Mindfulness is one of the four skills that are taught in

group skills training. It is considered the foundational skill that clients are taught before

the other skills.

“…The depth of the structure and the specific strategies and within a perimeter the

therapist has a lot of freedom for her own style of working with people. Its person

centered, and serves as a guideline…”

…”I could very easily get caught up in the client stories, and what DBT has offered

is the structure and framework to help the therapist figure out where he or she is

and bring the clients focus back to the structure of DBT or the targets in DBT. So

the framework is very helpful and the targets are helpful …”

According to one of the participants, “…Core mindfulness is like the other parent, it

runs through the other three modules. It is not more important but it is the basis and

the foundation of the other skills”.

Another participant indicated, “The mindfulness component is really a very key

component, which increases the client’s awareness of their own internal process”.

“I think what works best is that there is the structure of treatment for one thing.

Before I started in DBT, other models didn’t have the structure of knowing exactly

what a hierarchy of targets are what stages the treatment is in. It wasn’t clearly

defined as it is with Linehan…”

According to another therapist, “The structure of the program and knowing what is

expected of you and the client. A big piece of being able to identify their target

behaviors and we are able to do this through the structure and hierarchy of the

model”.

“…The targets because they are clearly outlined. I can get lost in some of the

clients tales. I am a good listener and would follow them in their stroeis and get lost

in them, so the targets help me as a therapist to stay focused on the targets that

were working on and the secondary targets which are the pieces you address such

as behaviors, emotions, thoughts that come up in sessions…”

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Biosocial Theory

Three respondents emphasized that the biosocial theory is a key element to

Dialectical Behavior Theory that makes it an effective treatment model when working

with clients diagnosed with Borderline Personality Disorder.

When one respondent was asked “what do you believe are the key elements to DBT

that make it an effective treatment model?” one participant responded, “In my

opinion the key elements to this treatment model are validation and change and

being in balance”.

When asked, “In your opinion why do you think DBT is one of the treatment models

that are most effective when working with BPD? A participant responded, “Well I

think the mindfulness component is a key element and I have said that a number of

times and I think there is another piece that I really like that I have learned in DBT is

that whole validation piece”.

When respondents were asked, “Can you describe to me the biosocial theory, and

what makes it one of the unique elements to the DBT treatment model?” One

respondent indicated, “An important element is also educating the clients about the

biosocial theory and also when the client comes to therapy it is powerful for them to

find out that there are other people like them. It is enlightening to them that other

people are sensitive and high reactive and it is not just them”

Another respondent stated, “The clients know exactly what that means (the biosocial

theory) and it gives them an understanding of why they act the way they do it is very

validating because they don’t blame themselves as much. They are able to say “I was

born more sensitive”. It reduces the shame”.

Another respondent stated, “The clients know exactly what that means (the biosocial

theory) and it gives them an understanding of why they act the way they do it is very

validating because they don’t blame themselves as much. They are able to say “I was

born more sensitive”. It reduces the shame”.

One respondent indicated, “…giving them that biosocial theory it helps them to see

why it happens and what is going on. I can’t go back and change it but I can repair it

and that is pretty powerful for them. It doesn’t place the blame on them, “I am who I

am and it’s not my fault”.

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Overall, educating the clients about the biosocial theory is an important piece because it

validates the clients and helps them cope

Dialectical Philosophy

All six of the participants identified the dialectical behavior philosophy as an

important element that contributed to the effectiveness of the DBT model. There were

several key words that came up throughout the interviews such as: acceptance, change,

dialectics, balance and validation.

When asked “what makes DBT treatment different than other cognitive behavior

therapy models?” One respondent indicated, “The specific acceptance piece, when

Marsha Linehan first came out with it, it is really amazing that anyone can put clients

first and accept them as they are”. One piece that makes it different is the acceptance

and specific strategies about acceptance and validation”.

When asked “What do you believe are the key elements to DBT that make it effective

treatment model” one respondent indicated, “The whole piece of dialectics is a central

part of the overall therapy. It allows me to think most effectively with this population.

The dialectical viewpoint, validation, problem solving, acceptance and change are huge

for this population. I find it very helpful when I need to push the client and when I need

to fall back”.

Furthermore, when one respondent was asked “In your opinion why do you think DBT

is one of the models that is most effective when working with this population?” The

respondent indicated, “I go back to the dialectics, because you need to have both. I

think with this population things are either all or nothing, their thinking is their

relationship and their emotions so it’s a key piece to teach dialectics. It is saying “I

accept you as you are now, and I expect you to change. The biggest dialectic is

change”..

“…One thing that I like about Linehan’s model is that she hops on the dialectics and

that it pushes you and it pushes the client to open up there thinking and it’s more

flexible in different options…”

One respondent indicated, “Family members can say wow! That’s what is going on

here, it’s not that we are blind, this child is different than the others”.

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Consultation Teams

Three out of the six participants identified the consultation team meeting among

therapist as a key element to this treatment model. The consultation team meeting serves

as an important piece because it gives the therapist support and helps them stay grounded

in their work with the clients. Without the consultation team meetings, a therapist

working with a client with BPD may feel burnt out and therefore not effective in therapy.

There are many reasons why the consultation team is a key element to Dialectical

Behavior Therapy such as it focuses on the therapist and not on the client. It is a part of

the treatment modality that gives support to the therapist in order for the therapist to be

effective in treating this population.

When one participant was asked “what are the key elements to this model that make

DBT so effective when working with this population?” the respondent indicated, “The

consultation teams for the therapist is an important piece of treatment so the therapist

doesn’t burn out. The therapist is able to gain competency and feedback from his or her

co-workers”

Another participant who was asked the same interview question, indicated, “you really

need support from consultation team and they really need to be calling you on your

behaviors that might be extreme behaviors you know like getting too involved with the

client, so you don’t have your perspective, so you have the consultation team to help

with that”.

“…When I talk to clients or the client’s parents or whoever, dialectics is having two

opposing truths and finding a synthesis or a balance. You have black and white but you want

to find grey. And we call that the ‘And therapy’ and not the ‘But therapy’”

“A crucial piece for the therapist is the consultation team meeting which provide

support for the therapist and gives an opportunity for the therapist to discuss his/her

caseload and get feedback from co-workers”

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Another respondent indicated that this was a crucial piece to the treatment

modality and serves as an essential part of support for the therapist. Because of the high

level of crises that this population deals with on a daily basis, it is essential that the

therapist aren’t getting burnt out and are getting support from their colleagues.

Chain Analysis

Three out of the six participants identified the chain analysis that is used in

therapy as being an important piece to Dialectical Behavior Therapy.

Discussion

There were six themes in DBT identified in this research paper: 1.

Structure/Hierarchy of the model 2. Core Mindfulness 3. Biosocial Theory 4. Dialectical

Philosophy 5. Consultation Teams 6. Chain Analysis. The following themes included a

A participant was asked, “In your opinion why do you think DBT is one of the treatment

models that is most effective when working with persons with BPD?” the response of the

participant was “…the client is able to get help and understand what their behavior is,

so the chain analysis helps them to see the light, and helps the mot see how they got there

and that to me has been one of the most powerful pieces of this model and I think that

teaches them a positive flow and instead of feeling hopeless it gives them hope”.

One participant indicated that the chain analysis is an important piece because it gives

the therapist an opportunity to go deep into what is going on and correct the behavior

using the chain analysis form. The responded indicated that “I do chain analysis and the

behavior changes really fast”.

One of the respondents indicated that when a client is abusing the phone coaching, the

respondent will use a chain analysis form in order to get understand what triggered the

crisis and that after the client completes the chain analysis and processes it with the

therapist the behavior disappears quickly.

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discussion on the findings and implications for further study and association with social

work.

Hierarchy of DBT Treatment Modality

All six participants acknowledged that the hierarchy of the DBT treatment model

was an important element to its effectiveness. Linehan states, “DBT is very specific on

the order and importance of various treatment targets” (Linehan, 1993). In Dialectical

Behavior Therapy, the most intense and fatal behaviors need to be changed first and then

the rest of the behaviors that need to be changed are on a hierarchy based on severity. The

purpose of the hierarchy is to keep the clients alive, and to work on specific areas based

on the importance of them in order for the client to live a life worth living (McMain,

Korman & Dimeff, 2001). The hierarchy of the model contributes to the effectiveness

because it guides the therapist and the client and helps them to stay on track with the

targeted goals, and helps the client and therapist to know what is expected of them. In the

hierarchy the therapist is able to identify target behaviors.

According to Linehan (1993), the central aim of DBT is that treatment targets

need to be clear and specific in order for this treatment model to be effective when

working with this high risk population. There are some requirements that the therapist

must follow when treating a client with DBT. The first thing is the therapist must identify

and have a clear understanding of what stage of therapy the patient is in at the time they

begin treatment. The therapist must also have a clear understanding of the targets with the

patient and how the targets relate to the patients treatment (Linehan, 1993).

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Core Mindfulness

Five out of the six participants acknowledge that core mindfulness is an important

element in Dialectical Behavior Theory when working with Borderline Personality

Disorder. Previous literature finds that mindfulness is an important element in this

treatment modality. Chapman (2006) indicated, “In DBT, several interventions and skills

are geared toward conveying acceptance of the patient and helping the patient accept him

or herself, others, and the world. One such intervention is mindfulness” (Chapman,

2006). Five respondents reported that mindfulness is an important element in this

treatment modality and the foundation skill that is taught throughout treatment. In

previous literature it indicates exactly what the practitioners in this study indicated that

Core Mindfulness is central to this treatment model, and the foundation and core skill that

is taught (Linehan, 1993, p. 44).

The Biosocial Theory

Three respondents acknowledged that the biosocial theory and educating the

clients on this theory is an important element to this treatment model. They believe this

theory can help the client in understanding and coping with this disorder and to be able to

reduce the shame and blame. It not only helps the client, it helps the family to be able to

understand why their child, or family member behaves the way he or she does

Dialectical Philosophy

All six participants acknowledged that the dialectical philosophy (validation,

change, acceptance and balance) are key elements to this model that make it effective

when working with clients with Borderline Personality Disorder. The dialectical

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philosophy is what makes this unique to this treatment model compared to other

Cognitive Behavior Therapy models. Several key themes were identified in coding, such

as the dialectical viewpoint is about maintaining balance, accepting the client, working

with the client toward change and validating the client. Finding balance was also viewed

as very empowering to the clients as it helps them to be able to see past the black and

white thinking. Moonshine (2008) states, “It empowers clients to see that reality is black

and white as well as a lot of shades of grey” (Moonshine, 39 2008). It is also accepting

the client and believing as their therapist that the client does have the ability to change

and to live a life worth living.

Consultation Team Meetings

Out of the six participants interviewed, consultation team meeting was considered

an important piece of this treatment model. The participants indicated that consultation

team meetings were an important piece considered it to be important for several reasons

such as to prevent burn out, to gain competency, get feedback and support, stay on track

with the treatment model, process the behaviors of the therapist and the client and it helps

the client to be centered. In previous literature it indicated that that consultation team

meeting is “an opportunity for the therapist to meet once a week with their treatment

team, sense of support, to decrease chances of burn out and opportunity to process

caseloads (Soler, et al., 2009).

Chain Analysis

Three out of six participants acknowledged that chain analyses are an important

element to the treatment model that makes it effective when working with clients with

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Borderline Personality Disorder. In order to change a problematic behavior, the therapist

will have to take a behavioral approach. The chain analysis gives the therapist and the

client an opportunity to identify the events that prompted the crisis and what could have

prevented the crisis from happening. The chain analysis is a detailed account, of what led

up to the event, what occurred throughout the event and how the crisis could have not

escalated (Miller, Koerner, & Kanter, 1998).

Strengths and Limitations

The purpose of this research study was to gain knowledge of what the specific key

elements of DBT are that make it effective when working with BPD clients. Strengths of

this research study are that it contributes to the limited amount of research on the key

elements of Dialectical Behavior Therapy that make it effective when working with

people diagnosed with Borderline Personality Disorder (BPD). The practitioners in this

study identified what, in their experience, they believed were the key elements that made

this treatment modality effective. As a result of this research study, practitioners are able

to identify and be aware of the key elements that contribute toward the effectiveness of

this model when working with people diagnosed with Borderline Personality Disorder.

Another strength of this study is that it is a qualitative study which consists of

interviewing more than half of licensed clinical social workers. This is an important

subject in the social work field because social work practitioners work with this

population on a daily basis. All six of the practitioners that were interviewed adhered

strictly to the Linehan model. This shows that the practitioners have knowledge and

experience in regards to this model when working with this population. Finally, it is

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important to understand what different practitioners believe to be the key elements to this

treatment model and what specific area should be enhanced in order for this population to

be treated effectively.

A limitation of this study is that all of interviews were conducted via telephone,

which could have held back the practitioners answers in their entirety. This may limit the

amount of data and results that the researcher obtains and may miss important non-verbal

information as well. Another limitation of this study is that all 6 of the practitioners that

were interviewed were from the Twin Cities Area. Therefore, the results of this study

cannot be generalized to other areas.

Implications for Social Work Practice, Policy and Research

There are several implications for the field of social work as a result of

information gained through this research study. Overall, the participants of the study

indicated that there is not just one element to Dialectical Behavioral Therapy that make it

effective when working with this population, it is a number of elements that come

together to make it effective. The results of this study are unable to be generalized

because of the small sample size, and lack of diversity in the sample, however if there

were more participants as well as more diversity in participation this would improve the

ability to see wider applicability. There is currently a lack of research in regards to the

key elements that make DBT effective when working with clients with BPD, so it would

be interesting if there was a larger sample size in order to gain more information in

regards to this topic.

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References

Ben-Porath, D.D., & Koons, R.C. (2005). Telephone coaching in dialectical behavioral

therapy: A decision tree model for managing inter session contact with clients.

Cognitive & Behavioral Practice, 12 (4), 448-460.

Bohus, M., Haaf, B., Stiglmayr, C., Pohl, U., Bohme, R., & Linehan, M. (2000).

Evaluation of inpatient Dialectical-Behavioral Therapy for Borderline Personality

Disorder – a prospective study. Journal of Behaviour Research and Therapy, 38,

875-887.

Chapman, L.A. (2006). Dialectical Behavior Therapy: Current Indications and Unique

Elements. Journal of Psychiatry. 62-68.

Dimeff, A.L. & Koerner, K. (2007). Dialectical Behavior Therapy in Clinical Practice:

Applications Across Disorders and Settings. The Guilford Press, New York, New

York.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders: DSM-IV-TR. Washington, DC: Author

Feigenbaum, J. (2007). Dialectical behavior therapy: An increasing evidence base.

Journal of Mental Health, 16 (1), 51-68.

Lindenboim, N., Chapman, A.L., & Linehan, M.M. (2007). Borderline Personality

Disorder. Handbook of Homework Assignments in Psychotherapy Research,

Practice and Prevention, Chapter 13, 227-245.

Linehan, M.M. (1993). Skills Training Manual for Treating Borderline Personality

Disorder. The Guilford Press, New York, New York.

Linehan, M.M., Comtois, A.K., Murray, M.A., Brown, Z.B., Reynolds, K.S., &

Lindenboim, N. (2006). Two-Year Randomized Controlled Trial and Follow-up

of Dialectical Behavior Therapy vs. Therapy by Experts for Suicidal Behaviors

and Borderline Personality Disorder. American Medical Association. 63, 757-766.

Lynch R.T., Trost, T.W., Salsman, N.,& Linehan, M.M. (2007). Dialectical Behavior

Therapy for Borderline Personality Disorder. The Annual Review of Clinical

Psychology 3, 181-205.

Mason, T.P & Kreger, R. (2010). Stop walking on eggshells. New Harbinger

Publications, Oakland, CA.

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McMain, S., Korman, L.M., & Dimeff, L. (2001) Dialectical Behavior Therapy and the

Treatment of Emotion Dysregulation. Psychotherapy in Practice, 57(2), 183-196.

Miller, L.A., Koerner, K., & Kanter, J. (1998). Dialectical Behavior Therapy: Part II.

Clinical Application of DBT for Patients with Multiple Problems. Journal

Practice Psychology and Behavioral Health. 84-101.

Moonshine, C. (2008). Acquiring Competency and Achieving Proficiency and Achieving

Proficiency with Dialectical Behavior Therapy, Volume 1: The Clinician’s

Guidebook. PESI, LLC. Eau Claire,Perroud, N., Nicastro, R., Jermann, F., &

Huguelet, P. (2012). Mindfulness skills in borderline personality disorder during

dialectical behavior therapy: Preliminary results. International Journal of

Psychiatry in Clinical Practice, 16, 189-196.

Porr, V. (2010). Overcoming Borderline Personality Disorder: A Family Guide for

Healing and Change. Oxford University Press, New York, New York.

Shearin, E.N. & Linehan, M.M. (1994). Dialectical behavior therapy for borderline

personality disorder: theoretical and empirical foundations. Acta Psychiatr Scand,

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Soler, J., Pascual, C.J., Tiana, T., Cebria, A., Barrachina, J., Campins, J.M., Gich, I.,

Alvarez, E., & Perez, V. (2009). Dialectical behavior therapy skills training

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Behavior Therapy Skills Use on Borderline Personality Disorder Features.

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Swales, M., Heard, H.L., & Williams M.G. (2000). Linehan’s Dialectical Behaviour

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Swenson, R.C., Sanderson, C., Dulit, A.R., & Linehan, M.M. (2001). The Application of

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inpatient units. Psychiatric Quarterly, 72(4), 307-324.

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Appendix A

Consent Form

Please read this form and ask any questions you may have before agreeing to participate

in the study. Please keep a copy of this form for your records.

Project Name: The Key Elements of Dialectical Behavior Therapy when working with

Borderline Personality Disorder

IRB Tracking Number: 395426-1

Statement about the study: This study examines Practitioners views on the key elements

of Dialectical Behavior Therapy that make it effective when working with persons

meeting the criteria for Borderline Personality Disorder (BPD). Dialectical Behavior

Therapy (DBT) is a Cognitive Behavior treatment approach that was designed by Marsha

Linehan to treat suicidal women meeting the criteria for BPD. The importance of this

research study is to examine Practitioners views on the key elements of DBT that make it

effective when working with persons with BPD. BPD is a widespread personality

disorder that has many serious effects, including high rates of suicide if it is not treated

effectively. There is few treatment models used to treat BPD that are evidence based.

DBT has been shown through several randomized clinical trials to be effective. There are

many elements of DBT such as different treatment targets, modes, strategies, biosocial

theory, and the dialectical philosophy that make this treatment model effective.

You are invited to participate in this research.

You were selected as a possible participant for this study because: You have an MSW

(Master of Social Work), a Master degree in Psychology, and have experience with

Dialectical Behavior Therapy (DBT) when working with clients meeting the criteria for

Borderline Personality Disorder (BPD).

Study is being conducted by: Cheryl A. Nickelson

Research Advisor: Karen Carlson

Department Affiliation: University of St. Thomas: School of Social Work

Background Information:

The purpose of this study is:

The purpose of this study is to find out what Practitioners view as the key elements in

Dialectical Behavior Therapy (DBT) when working with persons with Borderline

Personality Disorder (BPD). This study is important because this population is high risk

for suicide, and DBT is shown in other clinical research trials as one of the only effective

forms of therapy when working with this population.

Procedures

If you agree to be in the study, you will be asked to do the following:

Answer 14 research questions regarding your experience with Dialectical Behavior

Therapy when working with clients meeting the criteria for Borderline Personality

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Disorder (BPD). The interview will take approximately 30-45 minutes. I will be audio

taping the interview.

Risks and Benefits of being in the study

There are no risks involved with this study

There are no direct benefits involved with this study

Compensation

There will be no compensation

Confidentiality

That data will be kept in a locked file cabinet and the transcribed data will be kept on my

secured laptop that is protected with a password and only the researcher has access too.

On May 28th

, 2013 the data will be destroyed in its entirety by being shredded and

permanently deleted off of my secured laptop. The Researcher will be the only individual

that will have access to the data and records. Data identifying the subjects will not be

available to anyone another than myself.

Voluntary Nature of the Study

Your participation in this study is entirely voluntary. Your decision whether or not to

participate will not affect your current or future relations with any cooperating agencies

or institutions or the University of St. Thomas. If you decide to participate, you are free

to withdraw at any time up to and until the date/time specified in the study. You are also

free to skip any questions that may be asked unless there is an exception(s) to this rule

listed below with its rationale for the exception(s).

You may withdrawal from participating in this study at any given time.

Should you decide to withdrawal, data collected about you, will not be used in this study.

Contacts and Questions

You may contact any of the resources listed below with questions or concerns about the

study.

Research Name: Cheryl A. Nickelson

Research E-mail: Nick4324@stthomas.edu

Researcher Phone: 612-803-4127

Research Advisor Name: Karen Carlson

Research Advisor E-mail: carl1307@stthomas.edu

UST IRB Office: 651-962-5341

Statement of Consent:

I have read the above information. My questions have been answered to my satisfaction

and I am at least 18 years old. I consent to participate in the study. By checking the

electronic signature, I am stating that I understand what is being asked of me and I give

my full consent to participate in the study.

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Signature of Study Participant: ______________________________________________

Date: ___________________________________________________________________

Signature of Researcher: ___________________________________________________

Date: ___________________________________________________________________

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Appendix B

Interview Schedule

Demographic Questions

1. What is your professional licensure?

2. Can you describe your experience w/ Dialectical Behavior Therapy? Have you

had any training on it? How extensive was the training?

3. What type of treatment setting do you practice in? What is your title?

4. How long have you been working in this field w/ BPD & DBT?

Research Questions

5. Do you strictly adhere to the Linehan model? If no, what other models do you use?

6. Do you currently have any clients w/ BPD on your caseload? If not, when was the last

time you did?

7. In several research articles, it indicates that clients w/ BPD are difficult and

challenging to work with, tell me about your experience working with clients w/ BPD?

8. What is most effective when treating clients with BPD? What is least effective?

9. What are the challenges of working with this population under a DBT treatment

model?

10. What makes DBT treatment model different than other Cognitive Behavior Treatment

models?

11. What do you believe are the key elements to DBT that make it an effective treatment

model for treating clients with BPD?

12. There are four skill modules in DBT: Core mindfulness, Interpersonal effectiveness,

Distress tolerance, and Emotional regulation, which of these skills is most important

when treating BPD?

13. Within DBT treatment there are four treatment modes such as: Individual therapy,

Group Skills training, Phone Consultation and Consultation for therapist. Would you

consider one of these to be a key element to DBT treatment model? In your opinion,

which one is most important when treating clients with Borderline Personality?

14. In your opinion, why do you think that DBT is one of the treatment models that are

most effective when working with BPD?

15. In previous literature, it has stated that the biosocial theory and the dialectical

viewpoint are two unique elements to the DBT treatment model. Can you describe to me

in your opinion, the dialectical viewpoint and the biosocial theory and what makes it one

of the unique elements to this treatment model?

16. Is there anything you would like to add, that would further suggest what the key

elements to DBT treatment model that make it effective when working with clients with

BPD?

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Appendix C

Practitioner Contact Telephone Script

Hello, my name is Cheryl Nickelson. I am a graduate student at University of St.

Thomas/St. Catherine University MSW program and I am in the process of conducting

my clinical research paper.

I am conducting a qualitative study where I will interview 6-8 participants. The 14

interview questions will include demographic questions related to your background

experience and knowledge of working with this population under this treatment model. I

am wondering if you would like to be a part of this study?

If yes,

(Discuss with the participant the consent form and the process and schedule a time for the

interview). The interview would take approximately 30-40 minutes of your time. What is

your availability? Do you have any additional questions for me at this time? If you would

like I can send you a copy of the questions ahead of time in order for you to prepare.

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